Medical examination of players

NAME: (PRINT) First Last. College M#:

SPORT (s): NAME: (PRINT) First Last College M#: MONTGOMERY COLLEGE SPORTS MEDICINE PACKET INSTRUCTIONS: - 7/11 - DO NOT remove any papers this includes the four physical exam pages! - If downloading from

NEW STUDENT-ATHLETE MEDICAL HISTORY FORM

Student-Athlete Information NEW STUDENT-ATHLETE MEDICAL HISTORY FORM Name Date Birth SSN Sport Student ID Number Academic Class 1 Personal Physician s Name Phone # Person to Contact In The Event of Emergency

Texas Association of Private and Parochial Schools

Texas Association of Private and Parochial Schools P.O. Box 1039 601 N. Main Salado, Texas 76571 Date: April 1, 2014 254-947-9268 254-947-9368 (Fax) To: Head Administrators Athletic Directors Coaches Parents

WICOMICO COUNTY ATHLETIC PACKET

Emergency Form and Medical History LAST NAME: FIRST: M.I. SEX: MALE FEMALE Date of Birth: / / Sports: Grade: School: SSN: Parent/Guardian Home Phone Cell Phone Work Phone Emergency Contact-In the event

MOTORSPORT PERSONAL ACCIDENT PROPOSAL FORM

Hanleigh Management Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey 07677 Phone: (201) 505-1050 or (800) 443-2922 / Facsimile: (201) 505-1051 www.hanleighinsurance.com MOTORSPORT PERSONAL ACCIDENT

Life Insurance Application Form

Life Insurance Application Form INSTRUCTION To be completed by all applicants PERSONAL DETAILS Surname First name Middle name Sex Female Male Marital status (please tick) Single Married Other Current residential

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink)

SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey

Name (Full Given Name(s) and Family Name)

Queensland Government Coal Mine Workers Health Scheme - Health Assessment Form Section 46 Coal Mining Safety and Health Regulation 2001 Form Number CMSHR 1 (Form approved by Chief Inspector under section

Kaiser Permanente 2016 Sample Fee List *

Kaiser Permanente 2016 Sample Fee List * NORTHWEST What s a Sample Fee List? Knowing how much you can expect to pay for care and services can help give you peace of mind. As a deductible plan member, you

1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU

CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood

PATIENT INFORMATION INSURANCE INFORMATION

(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last

Implementing Medical Checkups to Prevent. Sports-Related Injuries and Disorders

Sports-Related Injuries and Disorders Implementing Medical Checkups to Prevent Sports-Related Injuries and Disorders JMAJ 48(1): 1 5, 2005 Hideo MATSUMOTO*, Toshiro OTANI**, Hitoshi ABE*** and Yasunori

Workman s Compensation

Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken

Kaiser Permanente 2016 Sample Fees List 1

Kaiser Permanente 2016 Sample Fees List 1 SOUTHERN CALIFORNIA Knowing how much you can expect to pay for care and services can give you peace of mind. This Sample Fees List shows you estimated fees for

GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434

GREENFIELD COMMUNITY COLLEGE H e a l t h Records Room N408 One College Drive, Greenfield, Massachusetts 01301 TEL: (413) 775-1431 FAX: 775-1434 HEALTH REQUIREMENTS M e d i c a l Assistant Certificate (

NEW PATIENT HISTORY Mark L. Prasarn, M.D.

NEW PATIENT HISTORY Mark L. Prasarn, M.D. Date: Name: Age: Height: Weight: Pharmacy: Phar. Phone#: Primary Care M.D. Referring M.D.: What is your Chief Complaint? What makes the pain better? Neck Pain

MHDO CompareMaine Updated: 9/17/2015

Office Visits -- Adult Preventative Care Office Visit (or Wellness Office Visit) 99385 New patient preventive care visit for adult, ages 18 to 39 99386 New patient preventive care visit for adult, ages

Including changes in health status since last exam. Known occupational exposures.

Firefighters Medical Checklist Individualized Health Risk Appraisal Written feedback to uniformed personnel concerning health risks and health status is required following the annual examination. Reporting

The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form.

The New Mexico Activities Association physical form provides schools, parents and providers with a recommended form. If the NMAA recommended Physical Form is to be used, please ensure that your child s

UNIVERSITI MALAYSIA PERLIS GUIDELINES TO FILL IN HEALTH EXAMINATION REPORT FOR POSTGRADUATE STUDENT

UNIVERSITI MALAYSIA PERLIS GUIDELINES TO FILL IN HEALTH EXAMINATION REPORT FOR POSTGRADUATE STUDENT 1. PLEASE READ THE INSTRUCTIONS CAREFULLY BEFORE FILLING IN THE FORM. 2. MEDICAL CHECK UP IS COMPLUSORY

INDIVIDUAL LIFE INSURANCE APPLICATION PART II - MEDICAL EXAMINATION

INDIVIDUAL LIFE INSURANCE APPLICATION PART II - MEDICAL EXAMINATION ReliaStar Life Insurance Company, 20 Washington Avenue South, Minneapolis, MN 55401 Security Life of Denver Insurance Company, 1290 Broadway,

Dallas Neurosurgical and Spine Associates, P.A Patient Health History

Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of

How To Fill Out A Health Declaration

The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance

NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION

NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)

Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.

: 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:

Step 1: Complete the attached Health Appraisal and Medical History Questionnaire, Goal Inventory, and Liability Waiver.

Please use the contact information below for questions or concerns. Abraham Lincoln High School Name: Eric Nicholson Email: Eric_Nicholson@dpsk12.org Phone: 7204235043 Bruce Randolph School Name: Greg

Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach

Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.

MOLLOY COLLEGE DIVISION OF NURSING NURSE PRACTITIONER PROGRAMS. Study Guide for the Basic Physical Assessment Exam

DIVISION OF NURSING S Study Guide for the Basic Physical Assessment Exam Questions will be based on following chapters in, Bickley, L.S. (2009). (10 th ed). Bates guide to physical examination and history

LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)

SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty

Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused by too little insulin, resistance to insulin, or both.

Diabetes Definition Diabetes is a chronic (lifelong) disease marked by high levels of sugar in the blood. Causes Insulin is a hormone produced by the pancreas to control blood sugar. Diabetes can be caused

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this

Dear Potomac State College Student Athletes and Parents:

Dear Potomac State College Student Athletes and Parents: We are please to have your son/daughter as a student athlete at Potomac State College of West Virginia University and hope that he/she will achieve

Adams Memorial Hospital Decatur, Indiana EXPLANATION OF LABORATORY TESTS

Adams Memorial Hospital Decatur, Indiana EXPLANATION OF LABORATORY TESTS Your health is important to us! The test descriptions listed below are for educational purposes only. Laboratory test interpretation

Kaiser Permanente 2015 Sample Fee List 1 Members in any deductible plan can use this list to help estimate their charges.

Kaiser Permanente 2015 Sample Fee List 1 Members in any deductible plan can use this list to help estimate their charges. COLORADO As your partner in health, we want to help you manage your health care

(Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Today s Date:

Page 1 of 5 (Please fill this out to the best of your ability) Baker Eye Institute Conway, Arkansas 501-329-3937 NAME: Age: What is the main reason for today s visit? Today s Date: Who referred you to

INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM

INFORMED CONSENT INFORMED CONSENT FOR PARTICIPATION IN A HEALTH AND FITNESS TRAINING PROGRAM NAME: DATE: 1. PURPOSE AND EXPLANATION OF PROCEDURE I hereby consent to voluntarily engage in an acceptable

Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.

Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex

Application for a Medical Impairment Rating (MIR)

STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers Compensation Division Medical Impairment Rating Program 220 French Landing Drive Nashville, TN 37243-1002 Phone (615) 253-1613 Fax

PPS UNDERWRITING GUIDE FOR APPLICANTS

PPS UNDERWRITING GUIDE FOR APPLICANTS UNDERWRITING guide 2013 WHAT HAPPENS WHEN YOU SUBMIT YOUR APPLICATION FOR INSURANCE? Once an application is submitted it is put through a number of processes to ensure

Height FT IN Weight Married? Y / N Employed? Y / N

Name Patient # (PLEASE PRINT) Signature Date Height FT IN Weight Married? Y / N Employed? Y / N Previous Illnesses: Check all that apply AIDS, HIV, STD Epilepsy Pacemaker Alcoholism Eye/vision problems

Department of State Academic Exchanges Participant Medical History and Examination Form

Department of State Academic Exchanges Participant Medical History and Examination Form Having been selected to participate in a U.S. Department of State educational exchange program, you are required

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM

NORTH CAROLINA HIGH SCHOOL ATHLETIC ASSOCIATION SPORT PREPARTICIPATION EXAMINATION FORM Patient s Name: Age: This is a screening examination for participation in sports. This does not substitute for a

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last

Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges

To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall 315-464-4260 (telephone) 315-464-5471 (fax) The New York Department

Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance

Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance INSTRUCTIONS - Please print all answers If required, retain a photocopy for your files. 1a) Plan contract number(s)

2015 Medical Requirement Forms

PLEASE RETAIN A COPY OF THE COMPLETED HEALTH FORMS FOR YOUR OWN RECORDS 2015 Medical Requirement Forms Ontario Public Health regulations and St. Clair College Policy require health screening for all persons

1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form

Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Virginia State law (code 23-7.5) requires all

Dr. Kenneth A. Giraldo, MD, P.A. Patient Controlled Substance Agreement Informed Consent Form

Dr. Kenneth A. Giraldo, MD, P.A. Patient Controlled Substance Agreement Informed Consent Form The following agreement relates to my use of controlled substance for chronic pain prescribed by Dr. Kenneth

Clinical Care Program

Clinical Care Program Therapy for the Cardiac Patient What s CHF? Not a kind of heart disease o Heart disease is called cardiomyopathy o Heart failure occurs when the heart can t pump enough blood to meet

Provided by the American Venous Forum: veinforum.org

CHAPTER 1 NORMAL VENOUS CIRCULATION Original author: Frank Padberg Abstracted by Teresa L.Carman Introduction The circulatory system is responsible for circulating (moving) blood throughout the body. The

Suspected pulmonary embolism (PE) in pregnant women

Suspected pulmonary embolism (PE) in pregnant women What is a pulmonary embolus? A deep vein thrombosis (DVT) is a blood clot that forms in one of the deep veins of the leg. If the clot moves to the lung,

Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by

Name Home phone Work phone Address Email address Date of birth Gender (circle): M F Marital status No. of children Name of partner Referred by Have you ever seen a Chiropractor? No Yes (Who?): Insurance

UW MEDICINE PATIENT EDUCATION. Aortic Stenosis. What is heart valve disease? What is aortic stenosis?

UW MEDICINE PATIENT EDUCATION Aortic Stenosis Causes, symptoms, diagnosis, and treatment This handout describes aortic stenosis, a narrowing of the aortic valve in your heart. It also explains how this

Medical examination form

Underwriting Medical examination form Questions 1, 2 and 3 of Section 1 are to be completed by the life insured prior to the examination. The medical examiner will discuss the answers with you and add

Dear Alderson Broaddus Student-Athlete:

Dear Alderson Broaddus Student-Athlete: Welcome back for another exciting year at Alderson Broaddus University! In preparation for the beginning of the academic year, and your participation in intercollegiate

GENERAL HEART DISEASE KNOW THE FACTS

GENERAL HEART DISEASE KNOW THE FACTS WHAT IS Heart disease is a broad term meaning any disease affecting the heart. It is commonly used to refer to coronary heart disease (CHD), a more specific term to

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE

ORTHOPAEDIC SPINE PAIN QUESTIONNAIRE NAME: DATE: ADDRESS: AGE: TELEPHONE#: RELIGION: OCCUPATION: REFERRED BY WHOM: NEAREST FRIEND/RELATIVE: TELEPHONE#: ADDRESS: PLEASE EXPLAIN WHY YOU HAVE COME TO SEE

6/3/2011. High Prevalence and Incidence. Low back pain is 5 th most common reason for all physician office visits in the U.S.

High Prevalence and Incidence Prevalence 85% of Americans will experience low back pain at some time in their life. Incidence 5% annual Timothy C. Shen, M.D. Physical Medicine and Rehabilitation Sub-specialty

VIRGINIA HIGH SCHOOL LEAGUE, INC. 1642 State Farm Blvd., Charlottesville, Va. 22911 Athletic Participation/Parental Consent/Physical Examination Form

Revised April 2007 VIRGINIA HIGH SCHOOL LEAGUE, INC. 1642 State Farm Blvd., Charlottesville, Va. 22911 Athletic Participation/Parental Consent/Physical Examination Form Separate examination is required

Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone

DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address

MEDICAL EXAM QUESTIONNAIRE APPLICATION SUPPLEMENT

Hartford Life Insurance Company Hartford Life and Annuity Insurance Company MEDICAL EXAM QUESTIONNAIRE APPLICATION SUPPLEMENT INSTRUCTIONS FOR THE MEDICAL EXAMINER DETACH AND DISCARD BEFORE MAILING THE

HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY

HEALTH SERVICES DEPARTMENT HEALTH HISTORY & PHYSICAL EXAM FORM HEALTH INFORMATION TECHNOLOGY Purpose: Completion of this packet is requested as part of the admissions process. The information you provide

Heart Center Packages

Heart Center Packages For more information and appointments, Please contact The Heart Center of Excellence at the American Hospital Dubai Tel: +971-4-377-6571 Email: heartcenter@ahdubai.com www.ahdubai.com

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)

Patient Name: Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK) (Last), (First) (Middle Initial) Address: City: State:

Notice of Privacy Practices

Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects

Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD

Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine

Personal Training Health Screening Questionnaire

Personal Training Health Screening Questionnaire Personal Information Today s date: Title: Dr. Mr. Mrs. Ms. Name: / Birth date: Last name First name Age: Address: Phone: (home) City: Phone: (work) Province:

Screening Examination of the Lower Extremities BUY THIS BOOK! Lower Extremity Screening Exam

Screening Examination of the Lower Extremities Melvyn Harrington, MD Department of Orthopaedic Surgery & Rehabilitation Loyola University Medical Center BUY THIS BOOK! Essentials of Musculoskeletal Care

Liver Function Essay

Liver Function Essay Name: Quindoline Ntui Date: April 20, 2009 Professor: Dr. Danil Hammoudi Class: Anatomy and Physiology 2 Liver function The human body consist of many highly organize part working

How To Participate In A Varsity Sport At A College Football Program

Athletic Training MEMO: Athletic Participation TO: DATE: FROM: All Varsity Student-Athletes and Parents For the 2007-2008 Academic Year Michael DeSavage, Head Athletic Trainer NEW Athletes & TRANSFERS

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:

Prescribed Minimum Benefit treatment guidelines

Prescribed Minimum Benefit treatment guidelines 05 Treatment guidelines for the Prescribed Minimum Benefit Chronic Disease List conditions The Prescribed Minimum Benefit Chronic Disease List is a list

Facts About Peripheral Arterial Disease (P.A.D.)

Facts About Peripheral Arterial Disease (P.A.D.) One in every 20 Americans over the age of 50 has P.A.D., a condition that raises the risk for heart attack and stroke. Peripheral arterial disease, or P.A.D.,

KNEE LIGAMENT REPAIR AND RECONSTRUCTION INFORMED CONSENT INFORMATION

KNEE LIGAMENT REPAIR AND RECONSTRUCTION INFORMED CONSENT INFORMATION The purpose of this document is to provide written information regarding the risks, benefits and alternatives of the procedure named

Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527

Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684

Thymus Cancer. This reference summary will help you better understand what thymus cancer is and what treatment options are available.

Thymus Cancer Introduction Thymus cancer is a rare cancer. It starts in the small organ that lies in the upper chest under the breastbone. The thymus makes white blood cells that protect the body against

General Internal Medicine Clinic New Patient Questionnaire

General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:

PATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:

PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email

Horton General Hospital Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Information for patients

Horton General Hospital Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Information for patients What is a Deep Vein Thrombosis (DVT)? A DVT is a blood clot which forms in a deep vein, usually in

P R E S E N T S Dr. Mufa T. Ghadiali is skilled in all aspects of General Surgery. His General Surgery Services include: General Surgery Advanced Laparoscopic Surgery Surgical Oncology Gastrointestinal

Coding and Documentation in Practice

Coding and Documentation in Practice Great Exam Documentation By: Kathy Mills Chang Kathy Mills Chang is a Certified Medical Compliance Expert, Reimbursement Consultant, Medicare Specialist, and a Documentation

Diuretics: You may get diuretic medicine to help decrease swelling in your brain. This may help your brain get better blood flow.

Hemorrhagic Stroke GENERAL INFORMATION: What is a hemorrhagic stroke? A hemorrhagic stroke happens when a blood vessel in the brain bursts. This may happen if the blood vessel wall is weak, or sometimes

EXECUTIVE BLOOD WORK PANEL

EXECUTIVE BLOOD WORK PANEL Below is a list of all blood and urine testing done on the day of your Executive Medical. MALE Serum Glucose Random Serum Glucose Fasting Creatinine Uric Acid Sodium Potassium

The insurance company checked above (Company) is responsible for the obligation and payment of benefits under any policy that it may issue.

American International Life Assurance Company of New York* Home Office: 80 Pine Street, New York, NY 10005 The United States Life Insurance Company in the City of New York* Home Office: 830 Third Avenue,

Gaston College Health Education Division Student Medical Form

Student Name: Date: Gaston College Health Education Division Student Medical Form Associate Degree Nursing Cosmetology Dietetic Programs Health and Fitness Science Medical Assisting Nursing Assistant Phlebotomy

Self- Lymphatic Massage for Arm, Breast or Trunk Lymphedema

Self- Lymphatic Massage for Arm, Breast or Trunk Lymphedema Patient Education Improving health through education The lymphatic system is part of our circulatory system. It helps balance the fluids of our

Fainting - Syncope. This reference summary explains fainting. It discusses the causes and treatment options for the condition.

Fainting - Syncope Introduction Fainting, also known as syncope, is a temporary loss of consciousness. It is caused by a drop in blood flow to the brain. You may feel dizzy, lightheaded or nauseous before

3. Your copayment is expected at the time of visit. We accept cash, checks, Visa, MasterCard and Discover. We do not accept American Express.

We would like to welcome you as a patient and thank you for choosing Central Virginia Orthopaedics & Sports Medicine to provide your orthopaedic needs. It is our mission to provide you the highest level

KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION

KU Summer Camp Registration Form 09 Please Print Clearly Due May 1, 2009 * REQUIRED INFORMATION 1 *Participant: *Name of School: *Name of Coach: *Camper/Commuter: Check One: June Cheer Camp June Dance

Cardiac Rehabilitation

Cardiac Rehabilitation Introduction Experiencing heart disease should be the beginning of a new, healthier lifestyle. Cardiac rehabilitation helps you in two ways. First, it helps your heart recover through

POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:

Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in

Diabetes Mellitus Type 2

Diabetes Mellitus Type 2 What is it? Diabetes is a common health problem in the U.S. and the world. In diabetes, the body does not use the food it digests well. It is hard for the body to use carbohydrates

MEDICATION GUIDE. PROCRIT (PRO KRIT) (epoetin alfa)

MEDICATION GUIDE PROCRIT (PROKRIT) (epoetin alfa) Read this Medication Guide: before you start PROCRIT. if you are told by your healthcare provider that there is new information about PROCRIT. if you are

MEDICAL HISTORY AND SCREENING FORM

MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems

Closed Automobile Insurance Third Party Liability Bodily Injury Claim Study in Ontario

Page 1 Closed Automobile Insurance Third Party Liability Bodily Injury Claim Study in Ontario Injury Descriptions Developed from Newfoundland claim study injury definitions No injury Death Psychological

Health Center Requirements Academy by the Sea/Camp Pacific

Health Center Requirements Academy by the Sea/Camp Pacific The information in this health packet is used to assist our health care professionals in providing proper care for your child. In an effort to

TERMS FOR UNDERSTANDING YOUR TYPE 2 DIABETES. Definitions for Common Terms Related to Type 2 Diabetes

TERMS FOR UNDERSTANDING YOUR TYPE 2 DIABETES Definitions for Common Terms Related to Type 2 Diabetes TYPE 2 DIABETES AND BLOOD SUGAR 1-3 This list of terms may help you beter understand type 2 diabetes,

Health questionnaire for the insured TAF life insurances

You are applying for life insurance. With your application goes a declaration of your health. You can fill out your declaration in this health questionnaire. When your application comprises of two insured

CARDIA 288 MONTH FOLLOW-UP SUPPLEMENTAL FORM (FORM B) HOSPITALIZATION CASE #: INTERVIEWER ID FY288BIVID2. Page 1 of 6 FY288BH4CN

HOSPITALIZATION CASE #: 2 8 8 0 H FY288BH4CN Has the participant indicated any of the following reasons for being admitted overnight for this case? 1. Suspected or confirmed problems with the heart, circulation,